Nursing Pay for Performance Model: Aligning Dollars with Outcomes

Nursing Pay for Performance Model: Aligning Dollars with Outcomes

0 comments | |

Current State: The US Healthcare system is undergoing unprecedented change, is the most advanced in the world, but often provides fragmented, costly and undervalued care (1). As part of the Affordable Care Act 2010 (2), patients, providers, payers and policy leaders are coming together to re-design care delivery, expand services, improve patient safety, reduce errors, and decrease total cost of care. Additionally, other regulatory agencies, such as the IOM (3) and CMS (4), recommended financial incentives to close gaps in care delivery, and develop new provider reimbursement programs. New models now include Value Based Purchasing (5) and Physician Pay for Performance (6), as novel approaches to drive quality and patient safety for improved population outcomes, and reduce healthcare expenditures. According to CMS, by 2018, 90% of healthcare payments will be tied to service, quality and performance measures (7).

Current Challenge: While strides have been made in quality and cost of care, frontline staff and nursing leaders are poorly engaged, and often exempt from financial reimbursement discussions at the organizational and national levels. Nursing services continue to be embedded as a fixed hospital daily bed charge (8). Unfortunately, nurses are undervalued, and individual nursing characteristics and contributions to patient care delivery has not been well defined (9). Thus, nurses are at the sharp end of care and can significantly impact patient safety, quality, and hospital performance outcomes (10). Therefore, starting in October 2014, under-performing hospitals with high rates of preventable harm, are now being penalized 1-3% of yearly CMS reimbursements as part of the Hospital Acquired Conditions (HAC) Reduction program (11).

Key Opportunity: Nursing Pay for Performance (P4P) is a key opportunity to be realized and leveraged NOW in the current healthcare-quality-reimbursement triad. There is an increasing push for discrete performance measures (12), where skilled nurses can practice at the top of their licensure (13). CMS (2) now requires publicly reported data for core performance measures and HAC scores, in order to promote high quality care that meets the National Quality Strategy (NQS) (14). Nurses have a unique opportunity to positively impact these areas to: (a) participate in the value of care delivery with practice accountability and transparency; and (b) receive appropriate reimbursements for their professional contributions to patient health outcomes, reducing HAC scores, and improving organizational performance metrics.

Benefits of P4P in Action: Nursing Code of Ethics (15) must be understood as a guiding principle for a successful P4P model. Nursing P4P incentive programs includes these key characteristics:

  • P4P is based on key perform measures that directly impact patient safety and quality of care, and align to the 2015 NQS (14) and the organization balanced scorecard.
  • P4P emphasizes a non-punitive, shared learning approach to build a culture of safety.
  • P4P uses standardized clinical outcome measures, such as Nurse Sensitive Indicators NDNQI (16) to measure, incent, and reward evidence-based practice.
  • Financial risks associated with incentive pay must not precipitate, force or drive compromises in clinical practice.
  • Nursing care delivery should not be compromised, diminished or lost because of the P4P performance program (17).
  • P4P programs should ultimately lead to: (a) greater nurse-patient satisfaction, and RN engagement; (b) reduced adverse events; and (c) improved hospital financials/budget.

Call for Collaboration with Nursing and Policy Leaders:

  • P4P is based on key perform measures that directly impact patient safety and quality of care, and align to the 2015 NQS (14) and the organization balanced scorecard.
  • P4P emphasizes a non-punitive, shared learning approach to build a culture of safety.
  • P4P uses standardized clinical outcome measures, such as Nurse Sensitive Indicators NDNQI (16) to measure, incent, and reward evidence-based practice.
  • Financial risks associated with incentive pay must not precipitate, force or drive compromises in clinical practice.
  • Nursing care delivery should not be compromised, diminished or lost because of the P4P performance program (17).
  • P4P programs should ultimately lead to: (a) greater nurse-patient satisfaction, and RN engagement; (b) reduced adverse events; and (c) improved hospital financials/budget.

In summary, it is time for nursing leaders to make quality and patient safety a priority with real-time nursing measures on the frontline. Policy Leaders need to include nursing pay for performance models as fundamental in the team based care delivery models of the future for the best patient outcomes based on reliable data that can be tied to patient and provider outcomes.


References

  1. Kurtzman, E., et al. (2011). Performance-Based Payment Incentives Increase Burden And Blame For Hospital, Health Affairs, 30, no.2 (2011):211-218
  2. US Government Department of Legislative Council. (2010). Patient Protection and Affordable Act 2010. Retrieved from http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW- 111publ148.pdf
  3. Institute of Medicine.(2007). Rewarding provider performance. Washington (DC): National Academies, Press; IOM.
  4. Medicare Payment Advisory Commission (2003). Report to the Congress: variation and innovation in Medicare. Washington (DC): MedPAC.
  5. US Department of Health and Human Services. (2014). Hospital Value-Based Purchasing. Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-    Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-     based-purchasing/
  6. Office of Research and Development Information. (2011). Optimal Pay-for-Performance Scores: How Incentivize Physicians to Behave Efficiently Using Episode-Based Measures. Centers for Medicare and Medicaid. Retrieved from https://www.cms.gov/Research- Statistics-Data-and-Systems/Statistics-Trends-and             Reports/Reports/downloads/MaCurdy_Incentivize_Physicians_Optimal_P4P_Scores_Fe   b_2011.pdf
  7. US Department of Health and Human Services. (2015). Better, Smarter, Healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value. Retrieved from http://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-           announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-     reimbursements-from-volume-to-value.html
  8. Welton, J., & Dismuke, C., (2008). Testing an Inpatient Nursing Intensity Billing Model. Policy, Politics, & Nursing Practice, 9(2), 103-111.  DOI 10.1177/1527154408320045
  9. Yakusheva, O., Linrooth, R., & Weiss, M. (2014). Nurse Value-Added and Patient Outcomes in Acute Care, Health Research and Educational Trust, Best of the 2014 Academy Health Annual Research Meeting. DOI: 10.1111/1475-6773.12236
  10. Mitchell, P. (2008). Patient Safety and Quality. In Agency for Healthcare Research and Quality, Defining Patient Safety, Chapter 1,( pp.  1-5). Rockville, MD.  Retrieved from             http://www.ncbi.nlm.nih.gov/books/NBK2681/
  11. Casey, A. (2015). Medicare’s Hospital-Acquired Condition Reduction Program, Hospital Policy Briefs, 34(10). Retrieved from http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=142
  12. National Quality Forum. (2004). National Voluntary Consensus Standards for Nursing- Sensitive Care: An Initial Performance Measure Set. Retrieved from https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=22094
  13. Institute of Medicine.(2015). Future of Nursing Leading Change, Advancing Health. Retrieved from http://iom.nationalacademies.org/Reports/2015/Assessing-Progress-on-      the-IOM-Report-The-Future-of-Nursing.aspx
  14. AHRQ. (2015). Report to Congress: National Strategy for Quality Improvement in Health Care. Retrieved from http://www.ahrq.gov/workingforquality/        
  15. American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Nursing World. Retrieved from http://www.nursingworld.org/DocumentVault/Ethics_1/Code-of-Ethics-for-Nurses.html
  16. Montalvo, I., (2007). National Database of Nursing Quality Indicators(NDNQI®), OJIN: The Online Journal of Issues in Nursing, 12 (3). DOI: 10.3912/OJIN.Vol12No03Man02
  17. American Nurses Association (1998). RNs and Pay-for-Performance: The Right Prescription? Policy # ANA 1998 rns-p4p-177.

Leave a Reply

Required fields are marked *.


Show Buttons
Hide Buttons